METASTASIS BONE

DISEASE
 DEFINITION

Metastatic disease, is the spread of cancer from an initial

or primary site in one organ or part of the body to a
secondary non adjacent organ or part.

Metastatic bone disease is the most common malignancy

of bone, it is estimated that 70% of all malignant bone
tumors are metastatic in origin.

Bone is the third most common site of metastatic process

after lung and liver. 80% of metastatic bone disease arise
from Ca of breast, prostate, lung, kidney and thyroid.

Typical location are thoracolumbal spine, pelvis, ribs, skull

and proximal of femur and humerus.
 DIAGNOSIS

Pain is an important symptom of musculoskeletal metastases,

but it is nonspecific. The pain pattern can be helpful if, in
addition to being activity related, it is present at rest and at
night, especially in patients older than 50 years..

Testing
• Laboratory tests that can be used to aid in the diagnosis of
metastatic bone disease include the following:
• Serum alkaline phosphatase: Indirect reflection of bone
destruction
• Serum protein electrophoresis
• Urinalysis, urine protein electrophoresis
• N-telopeptide of type II collagen: Marker of bone resorption
but not widely used
Imaging studies
The following radiologic studies may be used to evaluate
metastatic bone disease:
• Radiography: For the basic assessment of the extent of a
tumor and the degree of cortical erosion; can also be used for
skeletal survey in patients with multiple myeloma
• Computed tomography scanning: Most sensitive imaging
modality to detect bone destruction, providing the best
assessment of the extent of cortical destruction
• Magnetic resonance imaging: Most sensitive study for the
assessment of the anatomic (intramedullary and extraosseous)
extent of a lesion
• Bone scanning: Very sensitive study for the detection of occult
lesions and the assessment of the biologic activity of lesions
• Angiography: Depicts devascularization of vascular
metastases; may also be used to assess pain palliation in
patients with nonresectable metastases
Procedures
• Biopsies should be obtained from any soft-tissue mass or,
if no soft-tissue mass is present, from the most accessible
bone in a mechanically safe area (eg, metaphysis vs
diaphysis, acetabulum vs subtrochanteric femur).

In selected patients with metastatic disease of the spine,

the following diagnostic procedures may be performed:
• Percutaneous core needle biopsy
• Open biopsy
 MANAGEMENT

The life span of patients with metastatic bone disease is

limited; thus, the goal of management needs to be
centered on returning as much function as possible as
rapidly as possible. Patients with metastatic bone disease
are generally treated with surgery or radiation therapy.

Radiation therapy
• Radiation therapy remains a primary therapeutic
modality for the treatment of spinal metastasis, because
nearly 95% of patients who are ambulatory at the start of
radiation therapy remain so. Consequently, the
possibility of regaining cord function once it is lost as a
result of spinal metastasis is dismal. Therefore, such loss
needs to be avoided by early diagnosis, treatment, and,
if indicated, surgical intervention.
Surgery
• The goals of surgical intervention for spinal surgery in
patients with metastatic bone disease includes
decreasing or eliminating pain, decompressing neural
elements to protect cord function, and mechanically
stabilizing the spine. [1, 2] Anterior or posterolateral
decompression, combined with anteroposterior
reconstruction, may be used in the following:

Diagnostic spinal surgery

• Cervical spinal surgery
• Thoracic and lumbar spinal surgery
Vertebroplasty, in which polymethylmethacrylate is percutaneously
introduced, may be a minimally invasive treatment alternative for
patients with one- or two-level vertebral body compression fractures. [3]

For the management of long bone metastatic disease accompanied

by an impending or completed fracture, open internal fixation is usually
the preferred method of treatment. Stabilization with a locked
intramedullary device followed by radiation therapy to the entire bone
as soon as the surgical wounds have healed is preferred. [4]
Devices and/or procedures used in the surgical fixation of long
bones include the following:
• Standard or cemented stems
• Dynamic hip screws or plates
• Intramedullary fixation devices
• Total hip arthroplasty

Pharmacotherapy
Medications used in the treatment of metastatic bone disease
include the following:
• Monoclonal antibody antineoplastic agents (eg, denosumab)
• Calcium metabolism modifiers/bisphosphonates (eg,
pamidronate, zoledronate, and ibandronate)